What is perimenopause? Understanding the transition

The average age of menopause – the moment when you have not had your period for 12 consecutive months – is 51. Perimenopause is the transitional stage before that moment when you experience changes in hormone levels and menstrual patterns leading up to menopause. By 2030, the global population of people experiencing perimenopause will be about 1.2 billion, with an increase of 47 million each year.

Perimenopause is a completely normal and natural process, and an important milestone in your reproductive life cycle. It leads to the end of menstruation, as well as the beginning of a new life stage, and can bring with it a host of physical, mental, and emotional changes. Everyone’s perimenopausal journey looks different. Understanding what to expect from perimenopause will help you find more ease in your own unique experience of it.

Perimenopause vs menopause

Perimenopause and menopause are directly related to each other; think of perimenopause like the words in a sentence, while menopause is the period at the end. Although everyone shares the same final punctuation – the end of menstruation – the sentence leading up to that period varies widely in length, tone, language, and complexity. Only you and your body can write the perimenopause sentence that’s true for you.

On average, perimenopause starts in your 40s, but some may experience symptoms earlier or later than that and it can be challenging to determine an exact beginning. The road to menopause typically lasts 4 to 10+ years, and ends between the ages of 45 and 55 for most people. Having a final period after age 55 is considered late menopause and before age 45 is considered early menopause. If menstruation stops before the age of 40, this is a separate medical condition known as premature ovarian insufficiency (POI).

Signs and symptoms of perimenopause

Your perimenopause experience will be your own. Some people may have very mild symptoms and not notice much of a difference, while others may experience debilitating symptoms that greatly impact their daily lives. The following are some of the common signs and symptoms to pay attention to.

Hormonal changes

Although you’ll need to discuss testing options with your care provider to confirm any hormonal changes, it’s important to understand the primary cause of perimenopause. Fluctuating hormone levels are the root of most of the symptoms people experience, typically driven by a change in the amount of estrogen produced by the ovaries.

During a normal menstrual cycle, follicle stimulating hormone (FSH) signals the dominant maturing follicle to produce more and more estrogen as it prepares to release an egg, reaching a peak right before ovulation and influencing the production of luteinizing hormone (LH). Once the egg is released, progesterone climbs to a peak in preparation for pregnancy and then falls alongside the other hormones when menstruation occurs.

This repeated ebb and flow becomes less predictable as your ovaries age and follicles shut down. The ovarian response to FSH becomes inconsistent, which leads to more drastic peaks and valleys in estrogen that have a ripple effect on the downstream hormones associated with this cycle. This period of hormonal flux as your body prepares for menopause is the heart of the perimenopause experience.

Physical symptoms

The internal hormonal fluctuations have the potential to manifest into various physical symptoms. It’s important to recognize that these experiences are highly individual and can vary in intensity from person to person.

• Irregular menstrual cycles. This includes any changes in the time between periods, and in the duration and amount of menstrual flow you experience in comparison to your typical cycle.
• Hot flashes and night sweats. Also known as vasomotor symptoms, these are one of the most commonly recognized signs of perimenopause. An estimated 60 to 80% of people experience this symptom as part of their menopause journey.
• Sleep disturbances. An estimated 40 to 60% of perimenopausal people do not sleep through the night. Any insomnia challenges such as trouble falling asleep, frequent waking, and trouble going back to sleep can be exacerbated by hot flashes.
• Weight gain and metabolism changes. Even if exercise and food habits remain the same, you may still experience changes in both body composition and shape.
• Hair thinning and skin changes. Changes in estrogen levels can impact hair and skin. Hair can become thinner and more prone to breakage, while skin may become thinner, drier, and itchier. Genital dryness is also a common result of skin changes.

Emotional and cognitive symptoms

The hormonal shifts that accompany perimenopause can have a profound impact on both emotional and cognitive well-being. The changes you may face are real, and are part of a natural transition that affects everyone differently.

• Mood swings and irritability. Just like during PMS, fluctuating hormone levels can bring about sudden mood shifts. Irritability may also increase, sometimes triggered by stress or situations that would typically not affect you as strongly.
• Anxiety and depression. Mood disorders during perimenopause affect an estimated 10 to 20% of people. Changes in estrogen are a risk factor for depressive disorders, and disruptions in sleep can also compound mental health challenges.
• Memory issues and difficulty concentrating. While there is a limited body of research to explain the direct connection between hormones and feelings of mental fuzziness, 68.3% of perimenopausal people experience brain fog. And 74% of Gen Xers agree that perimenopause has interfered with work.

Perimenopause onset causes

The onset of perimenopause is influenced by three primary factors.

Natural aging process

Perimenopause is typically a result of the natural aging process, as ovarian function naturally decreases over time. When people approach their mid-to-late 40s (though it can happen earlier or later), their ovaries gradually begin to produce estrogen and progesterone in a very inconsistent manner, and these hormonal changes signal the body’s transition towards menopause.

Genetics

Genetics can play a role in the timing of perimenopause. If other family members went through perimenopause at an early or later age, your experience may mirror that pattern. While there is no single gene responsible for perimenopause, family history can help you know what to expect when starting this transition.

Medical treatments

Certain medical treatments can influence the timing of perimenopause. Surgeries such as a hysterectomy can lead to an earlier onset of perimenopause, particularly if the ovaries are removed at the same time. Even if the ovaries are preserved, the absence of the uterus can still trigger hormonal changes.

Additionally, treatments like chemotherapy or radiation therapy, particularly those targeting the reproductive organs, can lead to early or abrupt perimenopause by damaging the ovaries and impacting hormone production. The effects of these procedures on the reproductive system can vary depending on the type and duration of the treatment.

Diagnosing perimenopause

There is not a single, foolproof way to diagnose perimenopause because experiences vary so widely from person to person. However, there are multiple approaches your care provider can take to help you understand if your symptoms are due to perimenopause or not.

• Medical history review: Having an open and honest conversation about your physical, emotional, or cognitive symptoms, plus lifestyle and health history is key to determine if you’re experiencing perimenopause. Be sure to provide as much detail to your care provider as possible about your menstrual cycle patterns and the typical age menopause occurs in your family.
• Physical exams: During a physical exam, your care provider will assess your overall health and look for any signs that might point to perimenopause or other medical conditions. The exam may include checking vital signs, such as blood pressure and weight, and a pelvic exam to evaluate the health of your reproductive organs.
• Hormone level tests: Blood tests are commonly used to check hormone levels, specifically estrogen and follicle-stimulating hormone (FSH). Elevated FSH levels, alongside symptoms like irregular periods or hot flashes, can indicate perimenopause. However, it’s important to note that hormone levels can fluctuate throughout the perimenopausal transition, so a single blood test may not always provide a definitive answer. Multiple tests over time may be needed to track hormonal changes and gain a clearer picture.
• Differential diagnosis: Conditions like thyroid disorders, polycystic ovary syndrome (PCOS), and certain types of cancer can have similar symptoms to perimenopause, such as irregular periods, fatigue, and mood changes, so a differential diagnosis may be necessary. Your care provider can conduct additional tests to rule out these conditions and ensure your symptoms are truly related to perimenopause.

Treatment and management options

Navigating perimenopause requires a tailored approach, as the experience of this transition is deeply personal. Fortunately, if you’re in the 90% of perimenopausal people seeking help from your care provider, there are a variety of treatment and management options designed to alleviate symptoms and support your well-being.

Hormone replacement therapy (HRT)

What we used to refer to as HRT is now known as hormone therapy (HT), and it’s a commonly prescribed treatment for individuals going through age-related hormonal changes. Supplementing certain hormones, such as estrogen or progesterone, can help stabilize their levels and alleviate symptoms associated with the perimenopausal transition

Unfortunately, the last twenty years have been full of confusion and miseducation around HT thanks to an infamous 2002 study from the Women’s Health Institute that was inaccurately sensationalized by the media. The current consensus is that people under the age of 60 or people who start HT within 10 years of menopause gain both short-term and long-term benefits in the form of symptom relief and protection from chronic diseases.

Non-hormonal medications

In addition to HT, there are alternative medications that can be used to address perimenopausal discomfort and manage symptoms. For example:

• Antidepressants, particularly SSRIs and SNRIs, are commonly prescribed for managing mood changes, anxiety, and depression associated with perimenopause
• Gabapentin, a medication typically used to control epilepsy or nerve pain, affects nerve activity in the brain in a way that can also help with temperature regulation and sleep
• Clonidine, a medication typically used to treat high blood pressure, can also reduce hot flashes by affecting the brain’s receptors responsible for body temperature

This is a non-exhaustive list and your care provider may have other ideas for non-hormonal medications that could support you in your specific health situation.

Lifestyle modifications

In addition to medical treatments, lifestyle modifications play a pivotal role in managing the symptoms of perimenopause. By making mindful adjustments to your daily habits, you can improve both your physical and emotional well-being during this transition. Some top tips include:

• Exercise regularly to boost mood, energy, and sleep quality.
• Eat a balanced diet rich in calcium, vitamin D, and whole foods to support overall health.
• Manage stress through mindfulness, meditation, or deep breathing.
• Establish a consistent sleep routine to improve rest and recovery.
• Limit caffeine and alcohol to reduce sleep disturbances and mood swings.
• Stay hydrated to combat dryness and fatigue.
• Nurture your mental well-being by engaging in activities that bring you joy and fulfillment.

Natural remedies and supplements

Some people find relief for their perimenopause symptoms with natural remedies and herbs, such as black cohosh or ginseng. However, these supplements are not tested and regulated in the same way as medications, so there are unanswered questions about their effectiveness and the quality and purity of products sold cannot be guaranteed. If you’re thinking about incorporating a complementary remedy into your perimenopausal care plan, be sure to discuss this with your care provider.

Lifestyle tips for coping with perimenopause

Healthy eating

Research shows that nutritional habits are essential to maintaining a high quality of life throughout perimenopause and beyond. The building blocks of a healthy diet to support your hormonal health and reduce the symptoms of perimenopause include whole foods, plant-based meals, and calcium and soy-rich foods.

Soybeans and other soy-based products like miso, tempeh, and tofu can be particularly beneficial because they are a great source of phytoestrogens, which are compounds that mimic estrogen in the body. Ingesting phytoestrogens daily can reduce the occurrence of hot flashes by 20%. Flaxseeds are also a good source of phytoestrogens.

Calcium and vitamin D are especially important to protect bone density as you age, because the risk of osteoporosis increases as your estrogen levels decrease. The National Institute of Health recommends a daily intake of 1,000 to 1,200 IU of calcium and 600 to 800 IU of vitamin D for adults.

Examples of calcium-rich foods include yogurt, canned sardines, parmesan cheese, almonds, and leafy greens. Getting enough vitamin D can be challenging, especially if you spend most of your time indoors or live in a cloudy and/or dark climate. 42% of Americans are vitamin D deficient, so you may want to consider a supplement to reach the daily recommended amount.

Some other general nutritional tips to improve energy levels, regulate blood glucose, and maintain a healthy weight throughout your perimenopause transition include:

• Do not skip breakfast, eat regular meals throughout the day, and avoid large meals before bedtime
• Build a balanced plate – fill half with vegetables and include a palm-sized serving of lean protein
• Eat more whole grains and low glycemic starches, such as brown rice, quinoa, oats, lentils, beans, and sweet potatoes
• Include healthy fats from nuts, seeds, fish, and olive oil
• Minimize alcohol, caffeine, sugary snacks, and processed food
• Drink water and stay hydrated

Exercise

There are many benefits to maintaining a regular exercise routine as part of a healthy lifestyle. People who remain physically active through perimenopause tend to have a lower body mass index (BMI), more muscle mass, less body fat, and greater bone density.

Cardio and strength training are both great forms of moderate intensity exercise that can help reduce the symptoms of perimenopause, including hot flashes, insomnia, and depression. Strength training is particularly important because it can also help slow the bone loss that leads to osteoporosis.

The key thing to focus on when it comes to physical activity: move and stand more, sit less. You don’t have to put in hours at the gym to incorporate more movement into your life. Getting 5 to 10 shorter bursts of activity throughout the day can be as beneficial as an hour-long workout. The movement practices that are enjoyable and sustainable for you are the best types of exercise to add to your daily routine.

Sleep hygiene

Sleep plays a huge role in physical, mental, and emotional well-being. Since sleep disturbances are a common symptom of perimenopause, good sleep hygiene can become a valuable coping mechanism. A few thoughtful adjustments to your routine can significantly enhance the quality of your rest:

• Establish a consistent sleep schedule. Aim to go to bed and wake up at the same time each day, even on weekends. Consistency reinforces your body’s natural sleep-wake cycle.
• Limit napping. While a midday rest can be refreshing, avoid napping late in the afternoon or evening, as it may interfere with falling asleep at night.
• Create a calming bedtime routine. Engage in activities that signal to your body it’s time to wind down, such as reading, journaling, listening to music, or enjoying a warm bath.
• Minimize screen time before bed. The blue light emitted by devices can disrupt your body’s production of melatonin, which makes it harder to fall asleep. Keep phones, computers, and TVs out of the bedroom whenever possible.
• Maintain a comfortable sleep environment. Keep your bedroom at a moderate temperature and create a quiet, calming atmosphere to promote deeper sleep.
• Exercise regularly, but not close to bedtime. Regular physical activity supports better sleep, but avoid intense exercise in the evening, as it may leave you feeling too energized to rest.
• Be mindful of evening meals. Try to avoid large meals close to bedtime, as they can cause discomfort and disrupt your sleep. Opt for lighter, easily digestible snacks if needed.
• Limit caffeine late in the day. Caffeine from coffee, tea, and chocolate can stay in your system for hours and interfere with your ability to fall asleep.
• Reconsider alcohol. While alcohol may initially make you feel drowsy, it can disrupt the quality of your sleep and make it more likely to wake up during the night.

Mental health

Anxiety and depression are common symptoms of perimenopause, and you are not alone in your experience of this major life milestone. Seeking support and taking proactive steps to nurture your mental and emotional health can have a profound impact on your perimenopausal journey. Here are some ways you can protect your mental health during perimenopause:

• Acknowledge the connection. Mood fluctuations are a natural part of the perimenopause, and they can be intensified by other symptoms such as sleep disturbances or heightened stress. Understanding this link can help you manage expectations, respond more effectively, and have more compassion for yourself.
• Track your mood and triggers. Pay attention to changes in your mood, sleep, and stress levels to identify patterns that can help you manage your emotional well-being. If changes become intense or start to interfere with daily life, don’t hesitate to talk to a healthcare professional.
• Make thoughtful lifestyle adjustments. Simple, intentional changes such as increasing physical activity, prioritizing sleep habits, or trying new stress-reducing practices like meditation or yoga can be incredibly beneficial for emotional balance.
• Seek support. Remember, you don’t have to navigate this transition in isolation. Reach out to trusted friends, family members, or a care provider who can offer support, guidance, and reassurance during this time.
• Know that it’s temporary. While mood changes can be challenging, perimenopausal-related mental health conditions typically don’t last. Hormonal fluctuations during perimenopause are part of a natural process, and most emotional symptoms will gradually subside as you move through this phase.

When to see a doctor

While many of the symptoms associated with perimenopause are normal and manageable, there are times when it’s essential to seek professional medical advice.

• Severe symptoms: If the symptoms typically associated with perimenopause such as hot flashes, mood swings, or sleep disturbances become particularly severe or disrupt your daily life, you should consult a care provider. Similarly, while bleeding changes are normal during this time, The American College of Obstetricians and Gynecologists recommends seeing a care provider if you notice:
  • Bleeding or spotting between periods
  • Bleeding or spotting after sex
  • Heavy bleeding during your period
  • Bleeding that is heavier or longer than usual
• Mental health concerns: If symptoms of anxiety, depression, or mood swings become overwhelming or persistent, it’s crucial to reach out for professional support.
• Unusual symptoms: While perimenopause brings a variety of changes, certain symptoms may indicate underlying health conditions that need attention. For example, reach out to your care provider if you experience sudden or unexpected weight gain, severe headaches, chest pain, or significant changes in vision.

The impact of perimenopause on fertility

Perimenopause marks a significant transition in your reproductive years, and while fertility begins to decline naturally as ovulation becomes irregular, it doesn’t disappear entirely until menopause is reached.

Yes, it is still possible to conceive during perimenopause despite the decrease in quantity and quality of eggs. As long as you are still menstruating – even with irregular cycles – there’s a chance that you could get pregnant.

While pregnancy is still possible during perimenopause, it does come with increased risks. Pregnancy risks such as gestational diabetes, high blood pressure, chromosomal abnormalities (like Down syndrome), and miscarriage become higher with age.

Perimenopause is a natural transition, bringing a variety of physical, emotional, and cognitive changes driven by hormonal fluctuations. While symptoms like irregular periods, hot flashes, mood swings, and sleep disturbances are common, there are many ways to manage them through hormone therapy, non-hormonal medications, and lifestyle changes. By staying mindful of your health and seeking support, you can navigate this phase with more ease.